Recently, medical errors and their associated malpractice crisis have become a growing concern in healthcare, and now more than ever before, clinicians are required to better adhere to practice guidelines and documentation quality. These guidelines require appropriate and timely execution of medical evaluations, diagnoses, actions and decisions, as well as detailed and accurate documentation in the patient's chart.
The appropriate management of the patient's case involves a complex combination of essential information that must be evaluated pertinent to the specific clinical case and appropriately documented in a patient chart, and making the right diagnosis and the right management actions. The clinical situation may change from one moment to the next, based on the passage of time or developments in the patient's condition that require further evaluation of the clinical situation, documentation, diagnosis and decisions on management actions. These steps may include gathering additional data about the patient, performing additional tests or medical procedures on the patient and administering medication to the patient. Additionally, these steps can include the course of treatment scheduled to be performed or other clinical events. However, if a failure occurs along these complex processes, e.g. the appropriate evaluation is not done or not documented, the appropriate diagnosis is not made, the appropriate decisions are not made or the appropriate actions are not taken, each of those failures may lead to a catastrophic clinical error, which may lead to patient injury and malpractice events. The current method of patient management, when the staff is highly exposed to such failures in the real-time setting, is the primary reason for the growing concerns in the healthcare industry leading to a major need for quality control processes and mechanisms in healthcare to assure that a higher quality of practice is provided to the patients.
The present invention is designed to provide solutions to the failures in patient management described above by providing a method and system for assisting in real-time adherence to practice guidelines and essential medical and legal documentation standards. The present system and method presents clinicians, through specific alerts, reminders, suggestions and prompts, with the appropriate real-time case- and situation-specific care options, including the essential pertinent documentation, diagnosis, decisions and actions, and provides full support for best pertinent risk management pathways and documentation. The system also identifies the severity of the nearing failure and is able to escalate, as time passes, clinical reminders, prompts and alerts to avoid the clinical error, thereby serving as a powerful tool for quality assurance and malpractice reduction.